Background: Muscular dystrophy refers to a group of more than 30 genetic disease that causes progressive weakness and degeneration of skeletal muscles use during voluntary movement. There is no cure at this time, but physical therapy has been shown to improve quality of life. Muscular dystrophy is estimated to affect 250,000 individuals in the United States. Most of the research about this disease targets the Duchenne Muscular Dystrophy type, with little to no research regarding exercise in females with muscular dystrophy as well as adding in the impact of pregnancy. This case study was completed to highlight how a skilled physical therapist can impact a pregnant patient with muscular dystrophy in not only delaying further progression of the disease but demonstrating functional improvements.
Objectives: 18 yo. Female patient that had just been diagnosed with muscular dystrophy unknown subtype at 30 weeks pregnant was referred to physical therapy and occupational therapy. Patient’s complaints at this time included back pain with progressing scoliosis, increased difficulty with ambulation, difficulty carrying objects both during and prior to pregnancy. Patient currently undergoing genetic testing to discover the subtype. Comprehensive evaluation included assessment of any ROM deficits, strength testing, functional outcome measures included the Berg balance test, 4 stair climb timed test, 4 stair climbed test while carrying an object, ABC scale, FGA, 10MWT, and six minute walk test. Patient wanted to prepare herself for childbirth and caring for her child postpartum.
Approach: Plan of care was set for one-hour sessions twice a week for 8 weeks. Patient’s goals for therapy included improving her functional strength to care for her child and be physically prepared for childbirth. Due to outstanding factors, patient only attended 8 physical therapy sessions throughout her plan of care. Initial appointment was used for setting up a home exercise program emphasizing the importance of stretching of hip flexors and plantar flexors to prevent contractures as the disease progresses and hip abduction and extension strengthening exercises. Treatment interventions were focused around functional strengthening to meet the patient’s goals. Interventions included step ups progressing from bilateral upper extremity support to performing a flight of stairs while carrying an eight-pound medicine ball. For preparation for child birth, patient performed pelvic floor strengthening in a functional seated position with use of hand feedback for neuro reeducation. This exercise was progressed into more challenging positions such as quadruped and adding a secondary core engagement exercise with alternating upper extremity and lower extremity lifts. Another focus of the treatment included endurance training with use of stationary bicycle and ambulating while carrying an 8 pound object to simulate carrying her child.
Result: After eight sessions, patient reported a global rating of change of (+5) which equates to quite a bit better. Subjectively patient reported less fatigue even with progression of pregnancy. Berg Balance scale remained the same 56/56. Functional Gait Assessment improved by 2 points. Ten Meter Walk test increased from .96m/s to 1.25 m/s. Six-minute walk test improved from 348m to 425m. 4 stair climb improved from 5.89 seconds to 4.91 seconds and with an 8 pound med ball improved from 5.17 seconds to 5.01 seconds. Minimally clinically importance difference is unknown for this population in the literature.
Conclusion: Exercise is safe and effective for a patient with muscular dystrophy in the third trimester of pregnancy. Even with mixed reviews in the literature regarding exercise effectiveness for muscular dystrophy, this patient was able to demonstrate meaningful improvements in lower extremity strength, cardiovascular endurance, and functional activities with associated progression of pregnancy. Exercise prescription was decided utilizing recommendations from the American College of Obstetricians and Gynecologists with focusing strengthening large muscle groups and through knowledge of avoiding excessive fatigue in patients with muscular dystrophy. To ensure the exercises chosen were challenging use of the modified BORG scale was utilized.
Physical therapy has been shown to be effective in maintaining patient’s functional outcomes with muscular dystrophy. This patient’s case was unique as she was recently diagnosed with muscular dystrophy with no previous therapy received and while being 30 weeks pregnant. Physical therapists can aggregate the research to apply the most effective treatment interventions for patients with multi co morbidities. This case highlights the ability of the therapist to pull from exercise recommendations for Duchenne muscular dystrophy and pregnancy to design a specific exercise program related to the patient’s goals. Future research should focus on how therapy can impact a female across their lifespan with muscular dystrophy.